Title 27, Title 27 Title 27

(a) Benefit determination notification timelines. A healthcare entity and/or its review agent shall comply with the following: (1) For urgent or emergent healthcare services, benefit determinations (adverse or non-adverse) shall be made as soon as possible taking into account exi…

(a) Administrative and non-administrative appeals. The review agent shall conform to the following for the internal appeal of administrative or non-administrative adverse benefit determinations: (1) The review agent shall maintain and make available a written description of its a…

(a) General requirements. (1) In cases where the non-administrative adverse benefit determination or the final internal level of appeal to reverse a non-administrative adverse benefit determination is unsuccessful, the healthcare entity or review agent shall provide for an extern…

The office shall establish reporting requirements to determine if adverse benefit determination and/or utilization review programs are in compliance with the provisions of this chapter and applicable regulations as well as in compliance with applicable federal law.

(a) Whenever the employment of an insured member of a group hospital, surgical, dental, vision, or medical insurance plan is terminated because of involuntary layoff or death, or as a result of the workplace ceasing to exist, or the permanent reduction in size of the workforce, t…

The general assembly finds and declares that it is in the best interests of the residents of Rhode Island: (1) To strengthen and reform the governance structure of nonprofit hospital service and/or medical service corporations; (2) To ensure a diverse, independent, and publicly a…

In accordance with their nonprofit hospital and/or medical service corporation mission, nonprofit insurers shall be required to: (1) Offer products in the small group; (2) Offer products in the individual market, with at least one 30-day open enrollment period every twelve (12) m…

The terms of this chapter shall apply to any insurer or health maintenance organization, or other entity involved in delivering health insurance, whether or not organized as a nonprofit corporation, that is owned or controlled by a nonprofit hospital and/or medical service plan, …

(a) “Affiliate” means an entity controlled by, controlling, or in common control with, a nonprofit hospital service corporation. (b) “Health insurer” means an insurer defined in § 27-20.6-1(1).

All nonprofit hospital and/or medical service corporations and any affiliate or subsidiary of such corporation shall, on or before December 31, 2004, have a declared and published mission statement identifying the purposes of said nonprofit as including: (1) To provide affordable…

(a) The board of a nonprofit hospital and/or medical service corporation and its individual members are fiduciaries and shall act at all times: (1) In utmost good faith; (2) In a manner reasonably believed to be in the best interest of fulfilling the corporation’s mission or the …

(a)(1) Notwithstanding any public law, rule, or regulation to the contrary, six (6) positions on the board of directors of a nonprofit hospital and/or medical service corporation shall be filled by public appointment for a maximum of three (3) three-year (3) terms. Public appoint…

Neither a nonprofit hospital service corporation, nor an affiliate (as defined in 27-19.2-2) that is an insurer (as defined in § 27-20.6-1(1)), may take any of the following actions without the prior approval of at least two-thirds percent (66.67%) of the corporation’s entire boa…

(a) Pending appointment and confirmation of the health insurance commissioner, no compensation shall be paid to the board members by a nonprofit hospital or medical services corporation, excluding reimbursement for ordinary and necessary expenses. After such confirmation, the boa…

(a) There shall be a standing compensation committee of the board that shall develop proposed guidelines, for approval by the board, for compensation, including salary, bonuses, perquisites, and severance agreements, of all officers and executives that is reasonable. (b) On or be…

Each nonprofit hospital and/or medical services corporation shall adopt a code of ethics for its officers and directors that shall include, but is not limited to: a policy protecting the corporation and the public from conflicts of interest and abuse of position; a policy protect…

As used in this chapter: (1) “Dental service” means the professional services rendered by persons duly licensed under the laws of this state to practice dentistry, and prosthetic dentures, bridges, appliances, or other structures to be used and worn as substitutes for natural tee…

(a) Notwithstanding any other provisions of law, each domestic nonprofit dental service corporation shall be charged an assessment to partially support the activities of the division of insurance in the department of business regulation. (b) The minimum assessment charged shall b…

(a) Any rehabilitation, liquidations, administrative supervision, or conservation of a nonprofit dental service corporation organized under this chapter shall be conducted under the supervision of the director of business regulation pursuant to chapters 14.1, 14.2, and 14.3 of th…

All of the provisions of chapter 35 of this title apply to corporations organized or licensed pursuant to this chapter. Any approval granted by the director pursuant to chapter 35 of this title shall not supersede any other approval under Rhode Island law relative to mergers or o…

No provision of this chapter shall derogate from the common law or statutory authority of the attorney general nor shall any provision be construed as a limitation on the common law or statutory authority of the attorney general, including the authority to investigate at any time…

The director of the department of business regulation may adopt reasonable rules and regulations for the implementation and administration of the provisions of this chapter.

Any corporation organized under this title shall maintain total reserves for dental services, separate and distinct from reserves for other health services, in a dollar amount sufficient to pay claims for dental services and operating expenses for not less than one month. Those r…

(a) Any nonprofit dental service corporation that utilizes a formulary of medications for which coverage is provided under an individual or group plan master contract shall require any physician or other person authorized by the department of health to prescribe medication to pre…

(a) Definitions. As used herein: (1) “Maximum-allowable cost” or “MAC” means the maximum amount that a pharmacy benefits manager will reimburse toward the cost of a drug. (2) “Nationally available” means that there is an adequate supply available from regional or national wholesa…

A magnetic resonance imaging examination eligible for reimbursement by a nonprofit dental services corporation licensed pursuant to this chapter shall be reimbursed only if the provider at which the examination has been conducted and processed, and the licensed physician interpre…

(a) Every individual or group health insurance contract, plan, or policy delivered, issued for delivery, or renewed in this state that provides medical coverage that includes coverage for physician services in a physician’s office, and every policy that provides major medical or …

Every entity providing a nonprofit dental service plan as defined in this chapter shall allow, as a provision in a group or individual policy, contract, or health benefit plan for coverage of dental services, any person insured by the entity to direct, in writing, that benefits f…

(a) Except as otherwise provided herein, any review, audit, or investigation by a nonprofit dental service corporation of a healthcare provider’s claims that results in the recoupment or set-off of funds previously paid to the healthcare provider in respect to the claims shall be…

(a) Five (5) or more dentists duly licensed to practice under the laws of this state who are members of the Rhode Island State Dental Society and who first obtain authorization to do so by the Rhode Island State Dental Society, as evidenced by an affidavit of the president and se…

Every entity providing a nonprofit dental service plan as defined in this chapter shall notify all dentists providing services under a group or individual policy, contract, or health benefit plan for coverage of dental services, in writing, of any changes to its rules and regulat…

(a) No new or existing policy or certificate may contain any provision: (1) Purporting to reserve sole discretion to the insurance company to determine eligibility for benefits or interpret the terms of a policy or certificate; or (2) Specifying or affecting a standard of review …

Every nonprofit dental service corporation providing dental benefits to subscribers shall include on the identification card provided to its subscribers on the front of the cards the following language when the underlying plan contains a nonduplication of benefits clause: “NO DUP…

(a) Each nonprofit dental service corporation may contract with its subscribers for a dental service as may be provided under any nonprofit dental service plan adopted by the corporation. (b) The rates charged by the nonprofit dental service corporation to its subscribers shall b…

(a) Every nonprofit dental service corporation and any nonprofit dental service plan operated by a nonprofit hospital service corporation shall annually, on or before the first day of March in each year, file in the office of the commissioner of insurance a statement, verified by…

It is the duty of the director of business regulation at least every five (5) years to make an examination of the financial condition and methods of doing business of every nonprofit dental service corporation. The examination shall be performed, and the associated costs shall be…

No person shall be engaged to solicit subscribers to any nonprofit dental service plan upon a commission basis or upon any other basis by which the payment of the compensation or expenses of that person shall be conditioned upon the enrollment of subscribers, unless the method of…

(a) All nonprofit dental service corporations shall protect the interests of subscribers by promoting company solvency and financial strength through the application of investment standards that facilitate a reasonable balance of the following objectives: (1) To preserve principa…

Every nonprofit dental service corporation is declared to be, and shall be deemed to be, a charitable institution and shall be subject to the provisions of chapter 6 of title 7, except as otherwise expressly provided in this chapter, and to this chapter.

Any nonprofit hospital service corporation organized pursuant to the provisions of chapter 19 of this title that first obtains authorization to do so by the Rhode Island State Dental Society as evidenced by the affidavit of the president and secretary of the society may amend its…

As used in this chapter: (1) “Nonprofit optometric service corporation” means any corporation organized pursuant to this chapter for the purpose of establishing, maintaining, and operating a nonprofit optometric service plan. (2) “Nonprofit optometric service plan” means a plan b…

(a) Notwithstanding any other provisions of law, each domestic nonprofit optometric service corporation shall be charged an assessment to partially support the activities of the division of insurance in the department of business regulation. (b) The minimum assessment charged sha…

(a) Any rehabilitation, liquidation, administrative supervision, or conservation of a nonprofit optometric service corporation organized under this chapter shall be conducted under the supervision of the director of business regulation pursuant to chapters 14.1, 14.2, and 14.3 of…

All of the provisions of chapter 35 of this title apply to corporations organized or licensed pursuant to this chapter. Any approval granted by the director pursuant to chapter 35 of this title shall not supersede any other approval under Rhode Island law relative to mergers or o…

No provision of this chapter shall derogate from the common law or statutory authority of the attorney general nor shall any provision be construed as a limitation on the common law or statutory authority of the attorney general, including the authority to investigate at any time…

The director of business regulation may adopt reasonable rules and regulations for the implementation and administration of the provisions of this chapter.